Cocaine use during pregnancy assessed by hair analysis in a Canary Islands cohort

Toxicology as a diagnostic tool to identify the misuse of drugs in the perinatal period

The use, misuse, and abuse of substances are a continued public health concern in this country and around the world. Perinatal exposure to substances of abuse is associated with several long-term negative consequences for the neonate. Limited resources exist to assist perinatal health professionals on this very complex subject. The purpose of this document is to provide additional information about selecting monitoring protocols, the specifics of appropriate testing methodologies, and the interpretation of toxicological findings. Understanding these concepts better allows perinatal healthcare professionals to be a voice for the voiceless in order to protect and enrich lives during this unprecedented opioid epidemic.

Assessment of biological matrices for the detection of in utero cannabis exposure

Cannabis consumption has been increasing worldwide among pregnant women. Due to the negative effects of prenatal cannabis exposure, it is necessary to develop an objective, sensitive, and specific method to determine cannabinoids use during pregnancy. In this study, we compared four different biological samples, maternal hair, meconium, umbilical cord, and placenta, for the detection of in utero cannabis exposure. The biological samples were collected from 627 mother-newborn dyads. All hair and meconium samples were analyzed, and umbilical cord and placenta if hair and/or meconium were positive for cannabinoids. Meconium and hair showed to complement each other, with an agreement between hair and meconium results of 96.7% but only 34.3% if just positive results were considered. Umbilical cord and placenta results showed a better agreement with meconium (91.3% and 92.6%, respectively) than with hair (39.1% and 34.6%, respectively). The predominant metabolites in meconium were 11-nor-carboxy-THC (THCCOOH) and 8,11-dihydroxy-THC (diOHTHC), and in umbilical cord and placenta was THCCOOH-glucuronide. Cannabidiol (CBD) and cannabinol (CBN) were detected in meconium but not in any umbilical cord or placenta. For the first time, prenatal marijuana exposure was analyzed and compared in paired hair, meconium, umbilical cord, and placental samples. Hair and meconium positivity rate was similar, but a more sensitive and specific analytical method for the hair may resolve discrepancies between the matrices. Umbilical cord and placenta may be considered suitable alternative matrices to meconium through the determination of THCCOOH-glucuronide as a biomarker of cannabis exposure.

Role of Neonatal Biomarkers of Exposure to Psychoactive Substances to Identify Maternal Socio-Demographic Determinants

BACKGROUND

The accurate assessment of fetal exposure to psychoactive substances provides the basis for appropriate clinical care of neonates. The objective of this study was to identify maternal socio-demographic profiles and risk factors for prenatal exposure to drugs of abuse by measuring biomarkers in neonatal matrices.

METHODS

A prospective, observational cohort study was completed. Biomarkers of fetal exposure were measured in meconium samples. The mothers were interviewed using a questionnaire. Univariate and multivariate logistic regression analyses were performed.

RESULTS

A total of 372 mothers were included, 49 (13.2%) testing positive for psychoactive substances use: 24 (49.0%) for cannabis, 11 (22.5%) for ethyl glucuronide, six (12.2%) for cocaine, and in eight (16.3%) more than one psychoactive substance. Mothers who consumed any psychoactive substance (29.7 ± 6.6 years) or cannabis (27.0 ± 5.7 years) were younger than non-users (32.8 ± 6.2 years, p < 0.05). Cocaine (50.0% vs. 96.9%, p < 0.05) and polydrug users (37.5% vs. 96.9%, p < 0.05) showed a lower levels of pregnancy care. Previous abortions were associated with the use of two or more psychoactive substances (87.5% vs. 37.8%, p < 0.05). Single-mother families (14.3% vs. 2.5%, p < 0.05) and mothers with primary level education (75.5% vs. 55.1%, p < 0.05) presented a higher consumption of psychoactive substances. Independent risk factors that are associated with prenatal exposure include: maternal age < 24 years (odds ratio: 2.56; 95% CI: 1.12-5.87), lack of pregnancy care (odds ratio: 7.27; 95%CI: 2.51-21.02), single-mother families (odds ratio: 4.98; 95%CI: 1.37-8.13), and active tobacco smoking (odds ratio: 8.13; 95%CI: 4.03-16.43).

CONCLUSIONS

These results will allow us to develop several risk-based drug screening approaches to improve the early detection of exposed neonates.

Prevalence of Illicit Drug Use During Pregnancy: A Global Perspective

The World Drug Report 2019 presented an alarming figure to the world: more than 5% of the world's population has been using some type of illicit drug, and that number is growing every year. While its use increases, its abuse during pregnancy has become a global public health problem, resulting in medical and social challenges related to maternal and child health. In this context, the objective of this review was to determine the prevalence of illicit drug use during gestation across the globe, alongside with a critical review of the evaluated studies. Research was performed by simultaneously searching terms ("pregnant woman OR pregnant" OR "gestation" OR "pregnancy" AND "illicit drugs" OR "street drugs") in the databases of the Scientific Electronic Library Online, PubMed, and Web of Science. Comparisons between studies were performed in software Statistica 10.0. The data presented worrying results in relation to the variation in prevalence of illicit drug use during pregnancy, when comparing studies based on interviews or questionnaires (self-reported) (1.65%) and studies based on toxicological analysis (12.28%). In addition, we emphasize the high prevalence (5.16%) of illicit drug use among adolescent pregnant women and the low number of studies on this population. This study reveals worrying data about pregnant drug-user population, mainly the underestimation of prevalence in studies that use only questionnaires or similar methods in comparison to studies that use toxicological analysis of biological matrices. This scenario reveals necessity for health systems in different countries to establish specific public health policies for this population.

Drug testing in biological samples vs. maternal surveys for the detection of substance use during whole pregnancy

BACKGROUND

Early diagnosis of nicotine, ethanol and drug use during pregnancy is critical in order to provide adequate care. Current screening procedures show limitations in terms of reliability and short windows of detection.

OBJECTIVES

To investigate the prevalence and identify biomarkers of substance use and changes in substance use during pregnancy. To compare drug testing results in different types of biological samples (maternal hair, meconium, placenta, umbilical-cord) with self-reported data.

PARTICIPANTS AND SETTING

Prospective cohort study using data from pregnant women and their newborns.

METHODS

Biological matrices were collected at birth and analyzed by liquid chromatography tandem mass spectrometry. A paper survey was provided to determine substance use habits.

RESULTS

867 mother-newborn pairs were included. According to the analysis of biological samples, 29.1% cases were positive for one or more substances (13.6% nicotine, 8.4% ethanol, 8.3% cocaine, 6.4% cannabis, 5.7% opioids). The profile of the substance-using mother was a single woman, <28 years-old, with no higher education and unemployed. Segmental maternal hair analysis showed a decrease in tobacco, cannabis and cocaine use throughout pregnancy (p < 0.001). The level of concordance between results from interviews and from biological analyses was weak for opioids, cocaine, and cannabis (kappa coefficient < 0.40). Maternal hair detected the highest number of cases, followed by meconium and by placenta and/or umbilical-cord.

CONCLUSIONS

Maternal survey was not a reliable screening technique. Analysis of maternal hair detected the highest number of cases with the broadest detection window (whole pregnancy).

Prevalence of prenatal exposure to substances of abuse: questionnaire versus biomarkers

Alcohol and drugs of abuse consumption in young adults, including women of childbearing age, has experienced significant increase over the past two decades. The use of questionnaires as the only measure to investigate prenatal alcohol and drugs of abuse exposure underestimates the real prevalence of exposure and could mislead to wrong conclusions. Therefore, the aim of this article was to compare reported rates of prenatal alcohol and drugs of abuse consumption with biomarkers of exposure by a comprehensive review of the available literature. We searched MEDLINE and EMBASE databases for articles catalogued between 1992 and 2015. We identified relevant published studies that assessed the comparison between prenatal exposure to alcohol and drugs of abuse assessed by self-reported questionnaire of consumption versus biomarkers of exposure. Thirteen studies were included regarding alcohol consumption, and seven of them about drugs of abuse. Women who admitted consumption during pregnancy by questionnaire varied from 0 to 37% for alcohol, from 0 to 4.3% for cocaine, and 2.9% for tetrahydrocannabinol (THC). Positive biomarkers results ranged from 16 to 44% for alcohol, 15.4% for cocaine, and from 4 to 12.4% for THC. Biomarkers should always complement questionnaires, as it has been shown that self-report may underestimate prenatal exposure to substances of abuse.

Drugs of abuse in maternal hair and paired neonatal meconium: an objective assessment of foetal exposure to gestational consumption

In a prospective sample of 80 mother-infant dyads, we investigated whether drugs of abuse in maternal hair measured during the pregnancy trimesters were also present in neonatal meconium. Principal drugs of abuse were analyzed in the three consecutive maternal hair segments and meconium samples by ultra-performance liquid chromatography tandem mass spectrometry assay. Of the 80 mothers, 32 (40%) presented one or more hair shafts with at least one of the analyzed drugs of abuse and/or its metabolites. The drug of abuse with a higher prevalence in our study population was methamphetamine: 19 mothers had methamphetamine in one or more hair segments (59.4%). The second most detected drug of abuse was cocaine; nine mothers presented cocaine in one or more hair segments (28.1%). Nineteen pregnant women consumed at least one drug of abuse during the first trimester, ten continued consuming drugs of abuse during the second trimester; and nine consumed until the end of pregnancy. Five of the nine newborns from mothers who consumed drugs during the whole pregnancy showed drugs of abuse in meconium samples. Newborns from the 23 remaining mothers with one or two hair shafts positive to drugs of abuse did not present drugs in their meconium. Indeed from these results, it seems that discontinuous and/or sporadic consumption during pregnancy could produce a negligible transplacental passage and hence negative results in meconium. Furthermore, the role of placenta in the metabolism and excretion of drugs of abuse is still to be precisely investigated. Copyright © 2015 John Wiley & Sons, Ltd.

Bioanalysis during pregnancy: recent advances and novel sampling strategies

Consumption of drugs of abuse, tobacco and alcohol throughout pregnancy is a serious public health problem and results in an important economic cost to the health system. Drug and/or metabolites determination in biological matrices from mother and newborn is an objective measure of in utero drug exposure. We reviewed methods published for the determination of in utero drug exposure from 2007 to 2014, with special focus on meconium, placenta, umbilical cord and newborn hair. Accurate bioanalytical procedures are essential to obtain high-quality data to perform interventions and to establish correlations between analytical measures and clinical outcomes. We included a brief overview of clinical implications of in utero drug exposure to better understand the importance of this serious health issue.

Maternal and neonatal hair and breast milk in the assessment of perinatal exposure to drugs of abuse

Perinatal exposure to one or more drugs of abuse can affect the neonate temporarily or permanently. In addition to meconium, the evaluation of perinatal exposure to drugs of abuse has been achieved by testing biological matrices coming from the newborn (neonatal hair) and from the pregnant or nursing mother (maternal hair and breast milk). These matrices have the advantage of noninvasive collection and account for a sizable time window of active and passive exposure. Sensitive and specific analytical methods are required to determine minute amounts of drugs of abuse and metabolites in these matrices. The present manuscript reviews the newest analytical methods developed to detect drugs of abuse as well as ethanol biomarkers in maternal and neonatal hair and breast milk.

Prenatal exposure to substance of abuse: a worldwide problem

Substance abuse during pregnancy is an important public health issue affecting the mother and the growing infant. Preterm labor, miscarriage, abruption and postpartum hemorrhage are obstetric complications which have been associated with women who are dependent on abused substances. Moreover, women are also at an increased risk of medical problems such as poor nutrition, anemia, urinary tract infections as well as sexually transmitted infections, hepatitis, HIV and problems related to infection. Intrauterine growth restriction, prematurity, stillbirth, neonatal abstinence syndrome, and Sudden Infant Death Syndrome represent only some of fetal effects. Later on, during childhood, it has been shown that in utero exposure to substances of abuse is associated with increased rates of respiratory infections, asthma, ear and sinus infections. Moreover, these children are more irritable, have difficulty focusing their attention, and have more behavioral problems. Therefore, the assessment of in utero exposure to abused substance is extremely necessary and is relevant for the care of the mother and the offspring. In this sense, several approaches are possible; however, recently the evaluation of in utero exposure to abused drugs has been achieved by testing biological specimens coming from fetus or newborn, pregnant or nursing mother, or from both the fetus and the mother. Maternal and neonatal biological materials reflect exposure in a specific time period and each of them has different advantages and disadvantages in terms of accuracy, time window of exposure and cost/benefit ratio. The methodology for identification and determination of abused substances in biological materials are of great importance. Consequently, sensitive and specific bioanalytical methods are necessary to accurately measure biomarkers. Different immunoassays methods are used as screening methods for drug testing in the above reported specimens, however, the results from immunoassays should be carefully interpreted and confirmed by a more specific and sensitive chromatographic methods such as GC-MS or LC-MS. The interest in the development and optimization of analytical techniques to detect abused substances in different specimens is explained by the several possibilities and information that they can provide.

Emerging biomarkers of intrauterine neonatal and pediatric exposures to xenobiotics

Biomarkers are an important tool for clinicians to detect long-term exposure to a multitude of compounds, including drugs of abuse, alcohol, and environmental toxicants. Using hair and meconium as matrices for biomarker testing provides a longer window of detection than that of blood or urine, providing clinically relevant information on prenatal exposures. The use of biomarkers can aid clinicians in early diagnosis and implementing appropriate interventions. The increasing burden of environmental toxicants has warranted the development of biomarkers for specific compounds, which could decrease exposure in humans.